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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 E q. PERMIT EXPIRES 1 YEAR FROM DATE''ISSUED ' 3zt ,7( s (Complete in Triplicate) V ,/' �, € 9� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is fmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin y Local Health District.. f Job Address City- Lot Size PM �j PhoneI Owner's Na Address f ° Contractor i Address /lll License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO EAREST: SEPTIC SEWER LINES DISPOSAL�FLD. --PROP LINE ! FOUNDATION AGRICULTURE WELL _ _0T-HE F • ER"W LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL REA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ntti!il' Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑.Gravel P h L7 Tracy Typ Casing Specifications ("1 Public �i ther F1 Delta Depth of Gr Seal Type of Grout I I Irrigation ---Approx. Depth l I Eastern .Surface Seal Installs Rep ork Done ❑ Type of Pump H.P._ Stateork Done_ I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTI N I (No,septic system permitted if public sewer is I ) available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation- ° `Property Line I) LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line - SEEPAGE PITS;. I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line i j DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. i Home owner or'licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require inspections. Complete drawing on reverse side. i Signed XTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area, 61 Pit or Grout Inspection ate Fin spection _ Date I Additional Comments: ✓ -- I ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH ♦.EH 13-24 IREV.1/w 5) _ �. EH/4-2a `.